<?xml version="1.0" encoding="utf-8" ?>
<Content type="xform" name="PayForm">
  <model>
    <instance>
		<CreateNewBusiness>
			<UserName>string</UserName>
			<Password>string</Password>
			<Business>
				<PolicyClientReference>string</PolicyClientReference>
				<CustTitle></CustTitle>
				<CustForeNames></CustForeNames>
				<CustSurname></CustSurname>
				<CustAddress1></CustAddress1>
				<CustAddress2></CustAddress2>
				<CustAddress3></CustAddress3>
				<CustAddress4></CustAddress4>
				<CustAddress5></CustAddress5>
				<CustPostCode></CustPostCode>
				<CustHomeTel></CustHomeTel>
				<CustWorkTel></CustWorkTel>
				<AddCoverCode></AddCoverCode>
				<BankSortCode></BankSortCode>
				<BankName></BankName>
				<BankAddress></BankAddress>
				<BankAccountNumber></BankAccountNumber>
				<BankAccountName></BankAccountName>
				<BusinessType></BusinessType>
				<CreditAgreementDate></CreditAgreementDate>
				<CreditRenewalDate></CreditRenewalDate>
				<ClientPremium></ClientPremium>
				<NumInstalments></NumInstalments>
				<InstalmentAmt></InstalmentAmt>
				<SchemeBranch></SchemeBranch>
				<SchemeBrokerNo></SchemeBrokerNo>
				<TransID></TransID>
				<DepositAmt></DepositAmt>
				<ContractDate></ContractDate>
				<EntryType></EntryType>
				<PrefPaymentDate>1</PrefPaymentDate>
				<ChargePercentage></ChargePercentage>
				<SchemeCode></SchemeCode>
			</Business>
		</CreateNewBusiness>
    </instance>
    <submission id="payment" action="" method="POST" event="return form_check(this);" />
	  <bind nodeset="CreateNewBusiness/Business">
		  <bind id="CustTitle" nodeset="CustTitle" required="true()" type="string" />
		  <bind id="CustForeNames" nodeset="CustForeNames" required="true()" type="string" />
		  <bind id="CustSurname" nodeset="CustSurname" required="true()" type="string" />
		  <bind id="CustAddress1" nodeset="CustAddress1" required="true()" type="string" />
		  <bind id="CustAddress2" nodeset="CustAddress2" required="false()" type="string" />
		  <bind id="CustAddress3" nodeset="CustAddress3" required="false()" type="string" />
		  <bind id="CustAddress4" nodeset="CustAddress4" required="true()" type="string" />
		  <bind id="CustAddress5" nodeset="CustAddress5" required="true()" type="string" />
		  <bind id="CustPostCode" nodeset="CustPostCode" required="true()" type="string" />
		  <bind id="CustHomeTel" nodeset="CustHomeTel" required="true()" type="string" />
		  <bind id="CustWorkTel" nodeset="CustWorkTel" required="true()" type="string" />
		  <bind id="CustPostcode" nodeset="CustPostcode" required="true()" type="string" />
		  <bind id="confirmterms" required="true()" type="string" />
		  <bind id="SchemeCode" nodeset="SchemeCode" required="true()" type="string" />
		  <bind id="ChargePercentage" nodeset="ChargePercentage" required="true()" type="number" />
		  <bind id="ClientPremium" nodeset="ClientPremium" required="true()" type="number" />
		  <bind id="NumInstalments" nodeset="NumInstalments" required="true()" type="number" />
		  <bind id="InstalmentAmt" nodeset="InstalmentAmt" required="true()" type="number" />
		  <bind id="DepositAmt" nodeset="DepositAmt" required="true()" type="number" />
		  <bind id="BankName" nodeset="BankName" required="true()" type="string" />
		  <bind id="BankAddress" nodeset="BankAddress" required="true()" type="string" />
		  <bind id="BankSortCode" nodeset="BankSortCode" required="true()" type="string" />
		  <bind id="AcctHoldersName" nodeset="BankAccountName" required="true()" type="string" />
		  <bind id="AcctNumber" nodeset="BankAccountNumber" required="true()" type="string" />
		  <bind id="AcctReferance" nodeset="PolicyClientReference" required="true()" type="string" />
		  <bind id="PrefPaymentDate" nodeset="PrefPaymentDate" required="true()" type="number" />	  
	  </bind>
  </model>
	<group class="2col">
		   <label>Pay by 10 monthly Installments</label>
  <group ref="address">
    
	<div>
		<strong>Thank You.</strong>
		<p>For your own benefit and protection you should read the following documents carefully. Please confirm you have read and understood the documents:</p>
		<ul>
			<li><a href="/Policy+Wording" target="_new">Policy wording</a></li>
			<li><a href="/Terms+Of+Business" target="_new">Terms of business</a></li>
		</ul>
	</div>    
    <input bind="CustTitle" class="textbox required">
      <label>Title</label>
    </input>
	<input bind="CustForeNames" class="textbox required">
	  <label>ForeNames</label>
	</input>
	  <input bind="CustSurname" class="textbox required">
		  <label>SurName</label>
	  </input>
	  <input bind="CustAddress1" class="textbox required">
		  <label>Address Line 1</label>
	  </input>
	  <input bind="CustAddress2" class="textbox">
		  <label>Address Line 2</label>
	  </input>
	  <input bind="CustAddress3" class="textbox">
		  <label>Address Line 3</label>
	  </input>
	  <input bind="CustAddress4" class="textbox required">
		  <label>Town</label>
	  </input>
	  <input bind="CustAddress5" class="textbox required">
		  <label>County</label>
	  </input>
	  <input bind="CustPostCode" class="textbox required">
		  <label>Postcode</label>
	  </input>
	  <input bind="CustHomeTel" class="textbox required">
		  <label>Home Telephone</label>
	  </input>
	  <input bind="CustWorkTel" class="textbox required">
		  <label>Work Telephone</label>
	  </input>
	  <div>Please confirm that you are not falsely representing yourself or impersonating someone else with the details you are submitting for this policy and payment.</div>
	  <select ref="confirmterms" appearance="full">
		  <label></label>
		  <item>
			  <label>I agree</label>
			  <value>Agree</value>
		  </item>
	  </select>
  </group>
  <group ref="payDetails">
	  <label>Your Payment Details</label>
	  <!--select1 bind="SchemeCode" appearance="full" class="PaymentOption">
		  <label>Select a Payment Plan</label>
		  <hint>
			  If you decide to pay the premium on a monthly basis then it is subject to a typical 12.65%APR (variable). The credit agreement will be managed via Premium Credit Ltd, Premium Credit House, 60 East Street, Epsom, Surrey, KT17 1HB. The agreement is not subject to any deposit amount and the monthly payments will be collected over 10 repayments. The first instalment will be debited from your account with 14 days assuming successful set up of the agreement. Subsequent payments will be collected on, or as near as possible to, the anniversary of the inception date each month.
		  </hint>
	  </select1-->
		<input bind="SchemeCode" class="hidden"/>
		<input bind="BankName" class="textbox required">
			<label>Bank Name</label>
		</input>
		<input bind="BankAddress" class="textbox required">
			<label>Bank Address</label>
		</input>
		<input bind="BankSortCode" class="textbox required">
			<label>Bank Sort Code</label>
		</input>
		<input bind="AcctHoldersName" class="textbox required">
			<label>Account Holders Name</label>
		</input>
		<input bind="AcctNumber" class="textbox required">
			<label>Account Number</label>
		</input>
		<input bind="AcctReferance" class="textbox">
			<label>Account Referance (if applicable)</label>
		</input>
	  <input bind="PrefPaymentDate" class="textbox">
		  <label>Prefered Payment Date</label>
	  </input>
	</group>
	<submit submission="Submit" ref="confirmPaymentDetails" class="principle">
      <label>Confirm Payment by Monthly Installments</label>
	  <hint>The day of the month the payment is taken</hint>
    </submit>
</group>
</Content>
